Ear
wax defined

Ear wax is a normal product of the ear which protects the skin of the ear from
water and infection. Ear wax is formed from wax glands in the external ear canal
as well as other components such as dead skin, sweat, and oil. The primary component
of ear wax is keratin (derived from dead skin). Ear wax thus differs slightly
from cerumen which is the secretory product of the ceruminous glands
in the external auditory canal (Hawke, 2002). Ear wax is not a foreign body -- it is an intrinsic product of the lining of the ear. If you are interested in other stuff (like bugs), see this page.

While ear wax is generally simply
felt to be a nuisance, in medieval times, ear wax was used as a component of
pigment for illumination of manuscripts (Petrakis, 2000). Anthropologists have used cerumen type to tract human migratory patterns and epidemiologists have related cerumen type to breast cancer. (Roeser et al, 1997).

Different individuals vary considerably in the amount and consistency of their
ear wax. There are two types described, wet and dry, which are inherited. Dry
wax is common in Asia, while wet wax is common in western Europe. Dry wax, also
known as "rice-bran wax", contains by weight about 20% lipid (fat).
Oddly enough, rice-bran wax is associated with a lower incidence of breast cancer
(Hawke, 2002). According to Japanese researchers, a gene known as ATP-binding casette CII is important in controlling the type of ear wax you have. Without the contribution of this gene, one has dry (rice-bran) ear wax. (Yoshiura, Kinoshita et al. 2006). The high prevalence of dry wax may account for why the Japanese have so many
ways of removing it (i.e. mimikaki).

Wet wax consists of approximately 50% fat (Burkhart et al, 2000). Wet wax
can be either soft or hard, the hard wax being more likely to be impacted. Too
little ear wax increases the risk of infection (Fairey et al, 1985). Too much
wax also increases the incidence of infection and hearing loss. So, you want
just enough.

While we are not aware of a study of this, some people (and some ears) are
"wax producers", and others remain wax free without much maintenance. This has some impact on ear wax management (see below). Two populations are known to have a high incidence of excessive/impacted cerumen: individuals with mental retardation and the elderly. (Roeser et al, 1997).

Audiogram prior to ear wax removal (decreased hearing at both low and high pitches on the right (circles) compared to the left (x's).

Audiogram after ear wax removal.

What can go wrong with ear wax ?

Wax can plug up the ear, causing hearing to be reduced, and a full feeling
in the ear. This is called an "impaction". About 2-6% of the population has an ear wax impaction at any time. An example of the effect on hearing is shown above.

Wax can trap bacteria or fungus or other stuff in the ear, leading to infection. This is usually
painful or at least itchy.

How does one know one has ear wax ?

Direct vision is the easiest way. An otoscope is used to visualize the wax.

How is ear wax treated ?

Problematic wax can be removed with drops, with water jets ("irrigation"),
with suction, and with instruments by a doctor, audiologist or trained technician. If a person
has chronic ear disease, a perforation of the ear drum, or has wax in their
only hearing ear, it is recommended to have wax removed by an ear
doctor under direct vision. If there is a perforation in the ear drum, or a reasonable possibility of a perforation, wax should be removed by instruments and/or suction, and not by irrigation.

Wax removal under direct vision. A metal speculum (the trumpet
shaped device) is placed in the ear canal. Wax is removed using an instrument
called a "cerumen spoon", sometimes supplemented with gentle suction
and forceps. Ordinarily this is done using an examining microscope (not
shown), which provides magnification and a bright light.

These small impacted cerumen laying over the ear drum may cause up to 15db drop in hearing in long term hearing aid users. (Courtesy of Dr. Bulent Mamikoglu)

The best way:removal under direct vision by a doctor or other
professional is the best method of getting wax out, but it requires a doctors
visit and the doctor must have access to an examining microscope. Practically speaking,
this generally requires yearly visits to see a specialist called an "otologist".
The ear doctor will remove wax with a cerumen spoon, or suction, or both.

This method may be a little painful - not awful -- but not entirely pleasant. The reason is that wax is often embedded into the hair that grows onto the side of the ear canal. When one takes the wax out using a cerumen instrument, hair often comes with it -- this can hurt. This particular problem can be avoided by softening up the wax first with some oil (we often recommend Debrox) -- or by irrigating it out (see below).

In persons who have a very large amount of ear wax, putting drops into the ear may simply block up the ear and make it wet. Because of this consideration, the optimal method of doing this is to have someone look into your ear first, and act depending on the situation.

People accumulate wax at different rates, and also have different types of wax. Below is our usual algorithm for wax management:

No wax -- do nothing

Small amount wax -- do nothing

Moderate amount of wax -- take it out with microscope. Recheck in 6 months.

Large amounts of hard wax -- take out as much as can be easily removed with microscope, and have person use drops, return in a few days to a week for suction. Recheck in 3 months.

Large amounts of wax, already soft. Take out with suction or irrigation. Recheck in 3 months.

Irrigation:

Irrigation or "syringing" is a standard method of wax removal and approximately 150,000 ears are irrigated each week in the United States (Grossan, 1998). To avoid inducing dizziness, body temperature water is preferred. While irrigation is a conventional and accepted method of ear wax removal, it has many disadvantages compared to removal under direct vision. For example, in the rare instances when there is a perforation under the wax, irrigation may force water and wax into the middle ear, causing a nidus for infection. Irrigation also puts the ear to risk for bacterial infection. Some authors recommend placing 1 or 2 drops of Domeboro, Vosol or Cortisporin otic in the irrigated canal to prevent infection. Irrigation should not be used in ears with perforations.

Sometimes ear wax is hardened and impossible to remove with irrigation. In this situation one may attempt to soften the wax with oil and return in one week for another attempt. Suction may be helpful in this situation.

Water jet devices such as used for dental care have also been used for ear wax removal. While generally effective, this method is judged unpleasant by many patients. There is also danger of perforation of the ear drum using these devices. Special tips can be used to reduce or eliminate this risk.

The Welch Allyn Ear Wash System simultaneously irrigates and suctions out water and wax in a single step. This system is used in our practice in Chicago, and is very well tolerated. We also have a video otoscope that allows people to see their ear wax, "in situ", on a very large monitor. This is just if you really want to see whats in there.

Drops:

With respect to using drops, the current literature is inconclusive and basically suggests that nearly anything wet works as well as anything else. Over the counter drops that help remove wax are largely basically water, oil
and peroxide solutions (e.g. brand names are Debrox). Among the solutions are
ordinary water, 10% sodium bicarbonate, 3% hydrogen peroxide, 2% acetic acid,
and a combination of 0.5% aluminum acetate and .03% benzethonium chloride (Hawke,
2002). Hydrogen peroxide is present for the mechanical effect -- of course it does not
dissolve ear wax (Burkhart et al, 2000). These preparations are best for those
with small to moderate amounts of wax.

Among oil-based organic solutions are
olive oil, glycerin, propylene glycol, and others. Warming of solutions used
for wax removal sometimes is helpful. According to Hawke, oil based preparations
basically do nothing but lubricate (Hawke, 2002).

Some preparations are enzyme
based. We advise against use of "enzyme" based preparations, because
of problems with allergy.

NONE OF THESE PREPARATIONS SHOULD BE USED IN PERSONS
WHO HAVE A EARDRUM PERFORATION.

In many patients, a wax plug blocks the ear
so one cannot know for sure if a perforation is present. However in this situation,
it is usually possible to make an educated guess with a reasonable degree of
reliability (Hawke, 2002).

There are also preparations intended to dissolve ear wax -- for example, Cerumenex
Ear Drops and Murine Ear drops. Neither of these
preparations are any better than salt water. This is not to say that they are worthless -- just that salt water is equally effective (Roland et al, 2004).

Colace (a liquid stool softener), having the active ingrediant of docuate, when dropped in the ear, has also been studied for ear wax control. It has not been shown to have any advantages or disadvantages over other preparations. (see Cochrane Review). Docusate is ototoxic in guinea pigs (Nader et al, 2011), and for this reason, should be especially avoided when there is any chance of a perforation.

Dermotic drops are a mixture of oil and steroids. They can be used for itchy ears. They are not useful for ear wax per se.

"Candling" is an "alternative" method of removing wax.
This method is not felt to be effective. There is an obvious risk of burning your ear.

Ear Wax Maintenance

First, one should realize that wax isn't all that bad. It keeps your ear dry and helps
prevent infection. So, you don't want to eliminate wax, but just keep it from blocking
your ear.

How can one keep wax from blocking the ear ? There are several methods. The first two involve putting liquids into the ear, and should not be used by people with a hole in their ear drum (perforation).

One method is to put baby oil or olive oil into the ear on
a regular basis. Put in the drops, let it sit in there for a few minutes, then
lie down on a towel to let it drip out again. Probably only a few drops every
week in each ear is good enough (nobody has done a research study on this).
It doesn't hurt to put a few drops of clean olive oil or baby oil into each
ear every day. Swimmers often do this prior to their daily swim. However, be
sure that the oil is clean, as you don't want to introduce bacteria. This should
not be done if you have an eardrum perforation or if you don't know whether
or not you have a perforation.

A second method is to have one's doctor prescribe a 60 cc bottle of Domeboro
otic and place 2 drops of this solution into their ear weekly
after showering. The Domeboro solution supposedly stimulates migration of wax out of the
canal. We don't know of a study that proves that this is really true though.

Another method is to have your ear cleaned out by your doctor on a regular
basis. Everyone builds up wax at their own rate, but commonly people need to
come back for wax removal at 6 month or 1 year intervals.

When cotton tipped applicators are used to clean out ear wax,
there is a risk of breaking the ear drum (perforation). Although we realize
that this is commonly done, we recommend against using cotton tipped applicators,
hair pins, and similar devices to clean the ear.

We recommend against using cotton tipped applicators (the so-called 'Q' TIPS)
as well as putting other things into your ear such as hair pins. This can be
dangerous because you run the risk of breaking your ear drum ("perforation"),
as well as jamming wax deeper inside. Nonetheless, some people use Q-tips without
apparent harm. If you do use them anyway, in spite of the official recommendation
against doing so, caution is advised as well as limiting use to once per week.